Front Royal Family Practice, PC

140 West 11th Street

Front Royal, VA 22630

CONSENT FORM

(For Use and Disclosure of Protected Health Information for Treatment, Payment, or

Healthcare Operations)

I understand that as part of my healthcare Front Royal Family Practice originates and maintains health records

describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future

care and treatment. I also understand this information serves as:

A basis for planning my care and treatment

A means of communication among the many health professionals who contribute to my care

A source of information for applying my diagnosis and surgical information to my bill

A means by which a third party payer can verify that services billed were actually provided

And a tool for routine healthcare operations such as assessing quality and reviewing the competence of

healthcare professionals.

I understand and have been provided with a Notice of Information Practices that provides a more complete

description of information uses and disclosures. I understand that I have the right to review the notice prior to

signing this consent. I understand the practice reserves the right to change their notice and practices, and prior to

implementation, will mail a copy of any revised notice to the address that I have provided if there is a need to use or

disclose any protected health information. I also understand that I have the right to restrict as to how my health

information may be used or disclosed to carry out treatment, payment or healthcare operations and that the practice

is not required to agree to the restrictions requested, other than the exception noted in the Notice of Information

Practices. I understand that I may revoke this consent in writing, except to the extent that the practice has already

taken action in reliance thereon. Any patient, guardian or personal representative has the right to receive confidential

communications of protected health information by alternative means or at alternative locations. Such request must

be in writing and the practice must accommodate reasonable request.

With this consent, Front Royal Family Practice may call my home or other designated location and leave a message

on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment

reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With this consent, Front Royal Family Practice may mail to my home or other designated location any items that

assist the practice in carrying out TPO, such as appointment reminders and other correspondence as long as they are

marked Personal and Confidential.

With this consent, Front Royal Family Practice may e-mail to me appointment reminders and patient statements. I

have the right to request that Front Royal Family Practice restrict how it uses or discloses my PHI to carry out TPO.

However, the practice is not required to agree to my requested restrictions except for a request for a restriction on a

disclosure to a health plan where services have been paid in full, out-of-pocket, but if it does, it is bound by this

agreement.

By signing this form, I am consenting for Front Royal Family Practice to use and disclose my PHI to carry out my

TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance

upon my prior consent. If I do not sign this consent, Front Royal Family Practice may decline to provide

treatment to me.

Print Patient Name:____________________________________

Account Number:____________________

Signature of Patient or Legal Guardian:_________________________________

Date:___________________

Permission to Discuss Personal Health Information

Patient Name _______________________________________ D.O.B ____________________________

I hereby give permission to the person(s) listed below to receive information about the care of the

above named patient:

Name Relationship

_____________________________________ ____________________________________

_____________________________________ ____________________________________

_____________________________________ ____________________________________

_____________________________________ ____________________________________

_____________________________________ ____________________________________

_____________________________________ ____________________________________

_____________________________________ ____________________________________

____________________________________

Signature of Patient, Parent, Guardian

____________________________________

Date

In order to obtain information by telephone, the party calling the practice must share the patient

identifier with the staff.

Patient Identifier: _____________________________________________________________________

General Page 1

Front Royal Family Practice Registration Form

Patient’s Name (Last, First, MI):__________________________________________________________

Date of Birth:__________________ Age:_____ SSN #:____________________ Gender:_____________

Marital Status (Circle One): Married Single Separated Divorced Widowed

Employment Status (Circle One): Full Time Part Time Student Retired Unemployed Other

Home #:_____________________ Cell #:______________________ Work #:______________________

Email Address:________________________________________________________________________

Physical Address:______________________________________________________________________

Mailing Address:______________________________________________________________________

Emergency Contact:___________________________________________________________________

Relationship to Patient:____________________ Home #:________________ Cell #:________________

Primary Insurance Name:___________________ ID #:__________________ Patient is Subscriber: Y/N

Secondary Insurance Name:_________________ ID #:__________________ Patient is Subscriber: Y/N

Tertiary Insurance Name:___________________ ID #:__________________ Patient is Subscriber: Y/N

Please complete if patient is not the Subscriber(s):

Insurance Name:_________________ Subscriber Name:________________ Date of Birth:__________

Employer:___________________ Relationship to Patient:________________ Phone #:_____________

Please complete the following information to assist in Front Royal Family Practice providing diversified

care to the community.

Primary Preferred Language (Required):_____________________________

Please CIRCLE the option that applies to you

Race: Asian American Indian or Alaska Native African American Native Hawaiian White

Other Pacific Islander More than One Race Unreported/Refuse to Report

Ethnicity: Hispanic or Latino Not Hispanic or Latino Unreported/Refuse to Report

How did you hear about our Practice:_____________________________________________________

(Please turn form over to complete additional information)

Front Royal Family Practice Financial Policy

General Page 2

I certify that all information reported above is correct including my insurance information. I

authorize the release of any medical and financial information relating to services rendered be

released to my insurance carrier(s) by Front Royal Family Practice to obtain payment. I further

authorize payment of all medical insurance benefits for my services be made payable to Front Royal

Family Practice.

I understand it is my responsibility to know my insurance benefits prior to seeking services and that I

agree to render payment in which I am financially responsible. I understand that payment is due at

time of service unless prior arrangements have been made with the billing department. I understand

that Front Royal Family Practice will add a 35% collection fee along with interest for delinquent

balances. I understand delinquent balances may result in discharge from the practice. A copy of this

authorization may be used in place of the original in submitting claims for rendered services. This

authorization can be revoked in writing by me and/or my insurance carrier.

I understand if I am a self-pay patient that payment is due at time of service and that I may receive

additional bills from other entities (ex. Lab Company), which are separately payable from the

services paid to Front Royal Family Practice.

I understand any returned checks will be subject to a service charge for which I am responsible. And I

understand Front Royal Family Practice reserves the right to charge a fee for any scheduled visits

that are:

1. Missed without calling to cancel (No Show)

2. Arrive half past the appointment duration

3. Call to cancel less than 24 hours before appointment time

My signature certifies agreement of the above policy and that Front Royal Family Practice has

provided me a copy of the consent form.

Print Patient Name:_____________________________________ Account Number:________________

Signature of Patient/Guarantor/Legal Guardian:_________________________ Date:_______________

HEALTH HISTORY QUESTIONAIRE

Demographic Information

Patient Name (Last, First, M.I.):__________________________________________________________________

Date of Birth:___________________________________ Place of Birth:__________________________________

Sex:________________________________ Marital Status_____________________________________________

If married, spouse’s name:_______________________________________________________________________

Pharmacy Name and Location: ___________________________________________________________________

Current Medications: Please list or attach a list of medications

CURRENT MEDICATIONS

Drug allergies: No Yes

what?

Medication Reaction

1.

2.

3.

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:

Name of drug Dose (include strength & number of pills per day) How long have you been taking this?

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Please complete back of form

Past Medical History

PAST MEDICAL HISTORY

Do you now or have you ever had:

Diabetes Heart murmur Crohn’s disease

High blood pressure Pneumonia Colitis

High cholesterol Pulmonary embolism Anemia

Hypothyroidism Asthma Jaundice

Goiter Emphysema Hepatitis

Cancer (type) Stroke Stomach or peptic ulcer

Leukemia Epilepsy (seizures) Rheumatic fever

Psoriasis Cataracts Tuberculosis

Angina Kidney disease HIV/AIDS

Heart problems Kidney stones

Surgeries:

Date Procedure

Other medical conditions (please list):

WOMENS REPRODUCTIVE HISTORY:

Age of first period:

# Pregnancies:

# Miscarriages:

# Abortions:

Have you reached menopause? Y / N At what age?

Do you have regular periods? Y / N

Family History

FAMILY HISTORY

IF LIVING IF DECEASED

Age (s) Health & Psychiatric Age(s) at death Cause

Father

Mother

Siblings: Brother’s

Sister’s

Children: Daughter’s

Son’s

EXTENDED FAMILY HEALTH & PSYCHIATRIC PROBLEMS PAST & PRESENT:

Maternal Relatives:

Paternal Relatives:

Immunizations (check if Yes and indicate year of last injection)

___ Influenza ___ Pneumonia ___ MMR ___ Zostavax

___ Tetanus ___ Hepatitis A or B ___ Other ___ Shingrix

Please complete back of form

Patient Name (Last, First, M.I.):_____________________________________ Date of Birth:__________________

Number of years smoking? _____________________ Do you chew tobacco_____________ Have you thought about

quitting? ______________ Have you quit before?___________________ How long?_______________________

Alcohol Use:

Do you drink alcohol? ___________________If, so what type(s)? ______________________________________

How many drinks do you have in 1 week? _________________________________________________________

Drug Use:

Any history of recreational (illegal, pain medication) drug use? _______

If so, what type(s)?____________________________________________________________________________

When? _____________________________________________________________________________________

Disease Exposure:

Have you been exposed or currently (circle all that apply): AIDS, HIV, Herpes, Syphillis, Tuberculosis, SARS, and/or

Other(s)______________________________________________________________________________

Exercise/Nutrition:

Are you currently following a dietary lifestyle and/or regular exercise regimen? __________________________

How much caffeine do you consume on a daily basis?_______________________________________________

Employment:

Are you currently employed? _____________How many jobs are you currently working?___________________

Occupation__________________________________________________________________________________

List of providers other than Front Royal Family Practice who are involved in your care.

Physician/Practice Name:___________________Address:______________________Phone#________________

Physician/Practice Name:___________________Address:______________________Phone#________________

Physician/Practice Name:___________________Address:______________________Phone#________________

Physician/Practice Name:___________________Address:______________________Phone#________________

The information listed above is true to the best of my knowledge. If the information above changes I will notify Front Royal

Family Practice in writing.

________________________________ _____________________________________

Signature Date